Short term and intermediate term comparison of endarterectomy versus stenting for carotid artery stenosis: Systematic review and meta-analysis of randomised controlled clinical trials

Pascal Meier, Guido Knapp, Umesh Tamhane, Seemant Chaturvedi, Hitinder S. Gurm

Research output: Contribution to journalArticle

137 Citations (Scopus)

Abstract

Objective: To evaluate the relative short term safety and intermediate term efficacy of carotid endarterectomy versus carotid artery stenting. Design: Systematic review and meta-analysis. Data sources: BIOSIS, Embase, Medline, the Cochrane central register of controlled trials, International Pharmaceutical Abstracts database, ISI Web of Science, and Google scholar and bibliographies, from 1 January 1990 to 25 July 2009. Study selection: Randomised controlled trials comparing carotid endarterectomy with carotid artery stenting in patients with carotid artery stenosis with or without symptoms. Data extraction: Primary end point was a composite of mortality or stroke. Secondary end points were death, stroke, myocardial infarction, or facial neuropathy (as individual end points), and mortality or disabling stroke (as a composite end point). Data synthesis: 11 trials were included (4796 patients); 10 reported on short term outcomes (n=4709) and nine on intermediate term outcomes (1-4 years). The periprocedural risk of mortality or stroke was lower for carotid endarterectomy (odds ratio 0.67, 95% confidence interval 0.47 to 0.95; P=0.025) than for carotid stenting, mainly because of a decreased risk of stroke (0.65, 0.43 to 1.00; P=0.049), whereas the risk of death (1.14, 0.56 to 2.31; P=0.727) and the composite end point mortality or disabling stroke (0.74, 0.53 to 1.05; P=0.088) did not differ significantly. The odds of periprocedural myocardial infarction (2.69, 1.06 to 6.79; P=0.036) or cranial nerve injury (10.2, 4.0 to 26.1; P<0.001) was higher in the carotid endarterectomy group than in the carotid stenting group. In the intermediate term, the two treatments did not differ significantly for stroke or death (hazard ratio 0.90, 95% confidence interval 0.74 to 1.1; P=0.314). Conclusions: Carotid endarterectomy was found to be superior to carotid artery stenting for short term outcomes but the difference was not significant for intermediate term outcomes; this difference was mainly driven by nondisabling stroke. Significantly fewer cranial nerve injuries and myocardial infarctions occurred with carotid artery stenting.

Original languageEnglish (US)
Article numberc467
Pages (from-to)459
Number of pages1
JournalBritish Medical Journal
Volume340
Issue number7744
DOIs
StatePublished - Feb 27 2010
Externally publishedYes

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Endarterectomy
Carotid Stenosis
Meta-Analysis
Randomized Controlled Trials
Stroke
Carotid Endarterectomy
Carotid Arteries
Cranial Nerve Injuries
Mortality
Myocardial Infarction
Facial Nerve Diseases
Pharmaceutical Databases
Confidence Intervals
Information Storage and Retrieval
Bibliography
Odds Ratio
Safety

ASJC Scopus subject areas

  • Medicine(all)

Cite this

Short term and intermediate term comparison of endarterectomy versus stenting for carotid artery stenosis : Systematic review and meta-analysis of randomised controlled clinical trials. / Meier, Pascal; Knapp, Guido; Tamhane, Umesh; Chaturvedi, Seemant; Gurm, Hitinder S.

In: British Medical Journal, Vol. 340, No. 7744, c467, 27.02.2010, p. 459.

Research output: Contribution to journalArticle

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abstract = "Objective: To evaluate the relative short term safety and intermediate term efficacy of carotid endarterectomy versus carotid artery stenting. Design: Systematic review and meta-analysis. Data sources: BIOSIS, Embase, Medline, the Cochrane central register of controlled trials, International Pharmaceutical Abstracts database, ISI Web of Science, and Google scholar and bibliographies, from 1 January 1990 to 25 July 2009. Study selection: Randomised controlled trials comparing carotid endarterectomy with carotid artery stenting in patients with carotid artery stenosis with or without symptoms. Data extraction: Primary end point was a composite of mortality or stroke. Secondary end points were death, stroke, myocardial infarction, or facial neuropathy (as individual end points), and mortality or disabling stroke (as a composite end point). Data synthesis: 11 trials were included (4796 patients); 10 reported on short term outcomes (n=4709) and nine on intermediate term outcomes (1-4 years). The periprocedural risk of mortality or stroke was lower for carotid endarterectomy (odds ratio 0.67, 95{\%} confidence interval 0.47 to 0.95; P=0.025) than for carotid stenting, mainly because of a decreased risk of stroke (0.65, 0.43 to 1.00; P=0.049), whereas the risk of death (1.14, 0.56 to 2.31; P=0.727) and the composite end point mortality or disabling stroke (0.74, 0.53 to 1.05; P=0.088) did not differ significantly. The odds of periprocedural myocardial infarction (2.69, 1.06 to 6.79; P=0.036) or cranial nerve injury (10.2, 4.0 to 26.1; P<0.001) was higher in the carotid endarterectomy group than in the carotid stenting group. In the intermediate term, the two treatments did not differ significantly for stroke or death (hazard ratio 0.90, 95{\%} confidence interval 0.74 to 1.1; P=0.314). Conclusions: Carotid endarterectomy was found to be superior to carotid artery stenting for short term outcomes but the difference was not significant for intermediate term outcomes; this difference was mainly driven by nondisabling stroke. Significantly fewer cranial nerve injuries and myocardial infarctions occurred with carotid artery stenting.",
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AU - Knapp, Guido

AU - Tamhane, Umesh

AU - Chaturvedi, Seemant

AU - Gurm, Hitinder S.

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